Electronic Forms and Instructions

Instructions:  The following instructions are provided as guidance documents on several topics and applications/forms.

Application Information and Instructions

EPCI Q&A
Review Standard Instructions
Supplemental Finance Instructions

Special Notices:

  • A letter of intent must be submitted and processed separately prior to filing an application.
  • The Department no longer requires a separate certification form to be submitted with each application. Applicants are now required to confirm their certification and agreement to abide by the applicable Project Delivery Requirements in their direct responses to each assigned standard. Applicants filing paper applications should respond, as online filers do, by stating after each applicable Project Delivery Requirement section with the following statement, "As the authorized agent, I certify that the applicant will abide by the agreements and assurances required by this Section."

Electronic Forms:  The following electronic forms are available for filing letters of intent, applications, emergency applications, amendments, and required progress reports for approved projects. The Department encourages online filing of letters of intent, nonsubstantive, substantive, and emergency applications, and amendments through the CON e-Serve Application via the MILOGIN system (applications subject to comparative review must be filed in paper format).

For paper filings or paper forms still required with an electronic filing, please download the required form each time you need to use it. Outdated forms will not be accepted.

Form No. 

Title 

   
  Metro, Micro Statistical, and Rural Counties 
 
CON-004  Non-Substantive Routing Record - 07/16
CON-005  Substantive & Comparative Routing Record - 02/20

CON-100 

Application for CON - All Applicants - 07/16

CON-100 Instructions

Application Information and Instructions - 07/16

CON-101  Application for Emergency Certificate of Need - 07/16

CON-105 

Project Summary  - 07/16

CON-110-A 

Acquisition of Licensed Health Facility - 04/15

CON-110-B 

Bed Replacement/Relocation Report -04/15 
CON-110-C  Mobile Host Site - 04/15

CON-110-D 

Acquisition, Replacement or Relocation of a Covered Clinical Service - 04/15

CON-110-F 

Finance Report - 04/15

CON-110-i  Application for Change in Mobile Host Site-07/16
CON-113  Application for Swing Beds - 02/21

CON-144

Amended Request for CON -07/16

CON-145 Effective Dates of Standards -  03/21
CON-146 Expedited Processing Request - 06/18

CON-148 

Projects Eligible for Non-Substantive Review - 05/18

CON-149 

Letter of Intent - 07/16(Online VIA MILogin

CON-200 Section 22225 Excerpts of PA 368 of 1978 - 02/17

CON-200-A 

CON-200-C

Review Standards Instructions - 07/16

Certification of Planning Area-Bed Need - 09/19

CON-202  Lithotripsy Standards - 11/12/2019
CON-204  NICU Standards - 03/19/2021
CON-205  Psychiatric Beds Inpatient Standards - 11/12/2019
CON-206  Surgical Standards - 12/22/14
CON-208  Open Heart Surgical Standards - 06/02/2014
CON-209  Heart/Lung/Liver Transplant Standards - 09/28/2012
CON-210 

Cardiac Catheterization Standards - 09/14/2015

CON-210-B 

Request for Change to Interventional Cardiologist - 04/18

CON-210-C 

Historical Utilization Report AMI Cases Eligible for Primary PCI - 04/15

CON-210-D 

Historical Utilization Report Interventional Cardiologist Cases - 02/16

CON-210-E

Projection of Elective PCI Cases - 09/15

CON-210-F

Elective PCI Commitment Form Interventional Cardiologist Cases - 09/15
CON-211  MRT Standards - 09/14/2015
CON-212  CT Scanner Standards - 12/09/2016
CON-213  MRI Standards - 10/21/2016
CON-214  Hospital Beds Standards  - 03/20/2015
CON-217  NH-HLTCU Bed Standards - 03/19/2021
CON-217-A  NH-HLTCU Certification Report - 9/08
CON-217-B  NH-HLTCU Culture Change Model Worksheet - 02/18

CON-219 

Physician Commitment for MRI - 10/19

CON-220 

Physician Commitment for MRI Procedures - 04/15

CON-220-A 

Certification for Referring Doctor Commitment of Avail. MRI Adj.Procedures - 04/15

CON-222 

OH Surgery MIDB Data Release Authorization and Verification Form - 02/20

CON-226  Pancreas Transplantation Standards - Deregulated 09/28/2012
CON-227  PET Scanner Standards - 09/14/2015
CON-228  Air Ambulance Standards - 06/02/2014
CON-229  Bone Marrow Transplantation Standards - 09/29/2014

CON-230-A 

Lithotripsy Data Release Authorization - 10/15

CON-300 

Project Description - 07/16

CON-600 

Project Personnel Need - 07/16

CON-602 

MRT Staffing Report - 04/15

CON-700 

Inpatient Bed Utilization Report - 04/15

CON-704  Surgical Utilization Report - 04/15

CON-704-A 

Surgical Physician Commitment - 04/15

CON-704-F

Surgical Commitment Form for Facility (Same Owner) - 01/18

CON-706 

CT Utilization Report - 02/21

CON-706-A 

CT Physician Commitment - 02/21

CON-707 

MRT Utilization Report - 01/20

CON-707-A 

MRT Governing Body Resolution - 04/15

CON-707-B MRT Physician Commitment-8/17
CON-715  Lithotripsy Utilization Report - 04/15

CON-716 

Cardiac Catheterization Utilization Report - 12/18

CON-720 

Hospice Days of Care Report - 07/16

CON-732-A  PET Utilization Report - 04/15

CON-733 

PET Data Verification - 07/16

CON-733-A 

PET Sample of Governing Body Resolution for Submission of Data Commit. - 04/15

CON-733-B  PET Withdrawal of Data Commitments - 07/16

CON-800 

Physical Design Project Report - 04/15

CON-801 

Facility Area Report - 07/16

CON-802 

LTC Physicial Design Report - 07/16

CON-803  Facility Area Report LTC - 04/15
CON-804  Physical Design Report -07/16

CON-1000 

Equipment Report - 07/16

CON-1001  Major Equipment Report - 04/15

CON-1100

General Financing Questions - 07/16

CON-1105  Grants and Appropriations - 07/16
CON-1108  Hospital Utilization Statistics - 07/16
CON-1110  Hospital 5-Year Revenue & Expense Report - 07/16
CON-1114  NH Statement Revenue and Expense - 07/16
CON-1118  Revenue and Expense Statement Other - 07/16
CON-1200  Financed Projects - 07/16
CON-1202  Debt Service Coverage - 07/16
CON-1203  Amortization - 07/16

CON-1300

Project Implementation Progress Report - 08/16

CON-1400

Special Care Nursery (SCN) Follow-Up - 08/16
 
 

State of Michigan
Department of Health & Human Services - Certificate of Need Program
South Grand Building, 333 S. Grand Avenue, P.O. Box 30195
Lansing, MI  48909

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Updated November, 2020